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INTRODUCTION: Overdoses of beta-adrenergic antagonists and calcium channel antagonists represent an uncommonly encountered but highly morbid clinical presentation. Potential therapies include fluids, calcium salts, vasopressors, intravenous lipid emulsion, methylene blue, and high-dose insulin. Although high-dose insulin is commonly used, the kinetics of insulin under these conditions are unknown. CASE REPORT: We present a case of a 51-year-old male who sustained a life-threatening overdose after ingesting approximately 40 tablets of a mixture of amlodipine 5 mg and metoprolol tartrate 25 mg. Due to severe bradycardia and hypotension, he was started on high-dose insulin (HDI) therapy; this was augmented with epinephrine. Despite the degree of his initial shock state, he ultimately recovered, and HDI was discontinued. Insulin was infused for a total of approximately 37 hours, most of which was dosed at 10 U/kg/hour; following discontinuation, serial serum insulin levels were drawn and remained at supraphysiologic levels for at least 24 hours and well above reference range for multiple days thereafter. CONCLUSION: The kinetics of insulin following discontinuation of high-dose insulin therapy are largely unknown, but supraphysiologic insulin levels persist for some time following therapy; this may allow for simple discontinuation rather than titration of insulin at the end of therapy. Dextrose replacement is frequently needed; although the duration is often difficult to predict, prolonged infusions may not be necessary.
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Antagonistas de Receptores Adrenérgicos beta 1/envenenamiento , Amlodipino/envenenamiento , Bradicardia/tratamiento farmacológico , Bloqueadores de los Canales de Calcio/envenenamiento , Hiperinsulinismo/inducido químicamente , Hipoglucemiantes/administración & dosificación , Hipotensión/tratamiento farmacológico , Insulina/administración & dosificación , Metoprolol/envenenamiento , Bradicardia/inducido químicamente , Bradicardia/diagnóstico , Bradicardia/fisiopatología , Esquema de Medicación , Sobredosis de Droga , Humanos , Hiperinsulinismo/sangre , Hiperinsulinismo/diagnóstico , Hipoglucemiantes/sangre , Hipoglucemiantes/farmacocinética , Hipotensión/inducido químicamente , Hipotensión/diagnóstico , Hipotensión/fisiopatología , Infusiones Intravenosas , Insulina/sangre , Insulina/farmacocinética , Masculino , Persona de Mediana Edad , Intento de SuicidioRESUMEN
PURPOSE: To determine the etiology and outcomes of critically ill patients with severe hyperammonemia. MATERIALS AND METHODS: Retrospective observational study of adults (18 years or older) admitted to a MICU from 2007 to 2016 who had a serum ammonia level >180 µmol/L (3 times the upper limit of normal). RESULTS: The 78 patients (45 male, 32 female) had a median age of 52 (interquartile range [IQR] 46-58) years. Hyperammonemia occurred most often with acute-on-chronic liver failure (ACLF) (49 %) or decompensated cirrhosis (27 %) and less often as a consequence of prior gastric bypass (9%), acute hepatic failure (6%), or valproic acid (3%). Median serum ammonia level was 201 µmol/L (IQR 126-265, range 18-736) on admission, with peak value of 245 µmol/L (IQR 205-336, range 185-842). Fifty (64%) patients died during the hospitalization. Cerebral edema was documented in 8 (10%) patients, only one of whom survived. Six of the 8 patients with cerebral edema had hyperammonemia related to ACLF, giving an incidence of 14% in this subset of patients. Neither mortality nor cerebral edema was associated with peak ammonia level. CONCLUSIONS: Critically ill patients with severe hyperammonemia have a high mortality rate and are at risk of developing cerebral edema.
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Insuficiencia Hepática Crónica Agudizada/mortalidad , Enfermedad Crítica , Hiperamonemia/mortalidad , Insuficiencia Hepática Crónica Agudizada/diagnóstico , Adulto , Amoníaco/efectos adversos , Amoníaco/sangre , Edema Encefálico/fisiopatología , Femenino , Humanos , Hiperamonemia/complicaciones , Hiperamonemia/diagnóstico , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: Our objective was to examine the appropriateness of cardiac troponin (cTn) testing among patients with cTn increases. METHODS: This is a planned secondary analysis of the Use of TROPonin In Acute coronary syndromes (UTROPIA, NCT02060760) observational cohort study. Appropriateness of cTn testing was adjudicated for emergency department patients with cTn increases >99th percentile and analyzed using both contemporary and high-sensitivity (hs) cTnI assays according to sub-specialty, diagnoses, and symptoms. RESULTS: Appropriateness was determined from 1272 and 1078 adjudication forms completed for 497 and 422 patients with contemporary and hs-cTnI increases, respectively. Appropriateness of cTnI testing across adjudication forms was 71.5% and 72.0% for cTnI and hs-cTnI, respectively. Compared with emergency physicians, cardiologists were less likely to classify cTnI orders as appropriate (cTnI: 79% vs 56%, P < .0001; hs-cTnI: 82% vs 51%, P < .0001). For contemporary cTnI, appropriateness of 95%, 70%, and 39% was observed among adjudication forms completed by cardiologists for type 1 myocardial infarction, type 2 myocardial infarction, and myocardial injury, respectively; compared with 90%, 86%, and 71%, respectively, among emergency physicians. Similar findings were observed using hs-cTnI. Discordance in appropriateness adjudication forms occurred most frequently in cases of myocardial injury (62% both assays) or type 2 myocardial infarction (cTnI 31%; hs-cTnI 23%). CONCLUSIONS: Marked differences exist in the perception of what constitutes appropriate clinical use of cTn testing between cardiologists and emergency physicians, with emergency physicians more likely to see testing as appropriate across a range of clinical scenarios. Discordance derives most often from cases classified as myocardial injury or type 2 myocardial infarction.
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Síndrome Coronario Agudo/sangre , Troponina C/sangre , Adulto , Biomarcadores/sangre , Cardiología/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
BACKGROUND: We examined the diagnostic performance of high-sensitivity cardiac troponin I (hs-cTnI) vs contemporary cTnI with use of the 99th percentile alone and with a normal electrocardiogram (ECG) to rule out acute myocardial infarction (MI) and serial changes (deltas) to rule in MI. METHODS: We included consecutive patients presenting to a US emergency department with serial cTnI onclinical indication. Diagnostic performance for acute MI, including MI subtypes, and 30-day outcomes were examined. RESULTS: Among 1631 patients, MI was diagnosed in 12.9% using the contemporary cTnI assay and in 10.4% using the hs-cTnI assay. For ruling out MI, contemporary cTnI ≤99th percentile at 0, 3, and 6 h and a normal ECG had a negative predictive value (NPV) of 99.5% (95% CI, 98.6-100) and a sensitivity of 99.1% (95% CI, 97.4-100) for diagnostic and safety outcomes. Serial hs-cTnI measurements ≤99th percentile at 0 and 3 h and a normal ECG had an NPV and sensitivity of 100% (95% CI, 100-100) for diagnostic and safety outcomes. For ruling in MI, contemporary cTnI measurements had specificities of 84.4% (95% CI, 82.5-86.3) at presentation and 78.7% (95% CI, 75.4-82.0) with serial testing at 0, 3, and 6 h, improving to 89.2% (95% CI, 87.1-91.3) by using serial cTnI changes (delta, 0 and 6 h) >150%. hs-cTnI had specificities of 86.9% (95% CI, 85.1-88.6) at presentation and 85.7% (95% CI, 83.5-87.9) with serial testing at 0 and 3 h, improving to 89.3% (95% CI, 87.3-91.2) using a delta hs-cTnI (0 and 3 h) >5 ng/L. CONCLUSIONS: hs-cTnI and contemporary cTnI assays are excellent in ruling out MI following recommendations predicated on serial testing and the 99th percentile with a normal ECG. For ruling in MI, deltas improve the specificity. ClinicalTrials.gov Identifier: NCT02060760.
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Infarto del Miocardio/diagnóstico , Troponina I/análisis , Biomarcadores/análisis , Técnicas de Laboratorio Clínico , Femenino , Humanos , Masculino , Pronóstico , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Studies addressing patients with type 2 myocardial infarction and myocardial injury, including the impact of using high-sensitivity (hs) cardiac troponin (cTn) assays on their incidence are needed. METHODS: Ours is a prospective, observational US cohort study. Consecutive emergency department patients with serial cTnI measurements were studied. Outcomes included 180-day mortality and major adverse cardiac events, including 2-year follow-up for those with myonecrosis. RESULTS: Among 1640 patients, using a contemporary cTnI assay, 30% (n = 497) had ≥1 cTnI >99th percentile, with 4.7% (n = 77), 8.5% (n = 140), and 17% (n = 280) classified as type 1 myocardial infarction, type 2 myocardial infarction, and myocardial injury, respectively. Compared with patients without myonecrosis, 180-day mortality was higher for type 2 myocardial infarction (4% vs 13%, P < .0001) (adjusted hazard ratio 2.7; 95% confidence interval, 1.6-4.8; P = .0005) and myocardial injury (4% vs 11%, P < .0001) (adjusted hazard ratio 1.8; 95% confidence interval, 1.1-3.0; P = .02), both with mortality >20% at 2 years. Predictors of 2-year mortality for type 2 myocardial infarction included age, congestive heart failure, and beta-blockers. Relative to the contemporary cTnI assay, hs-cTnI had less myonecrosis (30% vs 26%, P = .003) and acute myocardial infarction (13.2% vs 10.8%, P = .032), including fewer type 2 myocardial infarctions (8.5% vs 6.3, P = .01), with no difference in myocardial injury (17% vs 15%, P = .1). CONCLUSIONS: cTnI increases are encountered in approximately a third of patients, the majority due to nonatherothrombotic conditions. Compared with patients without myonecrosis, type 2 myocardial infarction and myocardial injury have worse short-term outcomes, with mortality rates >20% at 2 years. hs-cTnI assay does not lead to more myocardial injury or infarction.
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Lesiones Cardíacas/sangre , Infarto del Miocardio/sangre , Infarto del Miocardio/clasificación , Troponina I/sangre , Femenino , Lesiones Cardíacas/diagnóstico , Lesiones Cardíacas/epidemiología , Lesiones Cardíacas/terapia , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: International Classification of Diseases (ICD) coding is the standard diagnostic tool for healthcare management. At present, type 2 myocardial infarction (T2MI) classification by the Universal Definition of Myocardial Infarction (MI) remains ignored in the ICD system. We determined the concordance for the diagnosis of MI using ICD-9 coding vs the Universal Definition. METHODS: Cardiac troponin I (cTnI) was measured by both contemporary (cTnI) and high-sensitivity (hs-cTnI) assays in 1927 consecutive emergency department (ED) patients [Use of TROPonin In Acute coronary syndromes (UTROPIA) cohort] who had cTnI ordered on clinical indication. All patients were adjudicated using both contemporary and hs-cTnI assays. The Kappa index and McNemar test were used to assess concordance between ICD-9 code 410 and type 1 MI (T1MI) and type 2 MI (T2MI). RESULTS: Among the 249 adjudicated MIs using the contemporary cTnI, only 69 (28%) were ICD-coded MIs. Of 180 patients not ICD coded as MI, 34 (19%) were T1MI and 146 (81%) were T2MI. For the ICD-coded MIs, 79% were T1MI and 21% were T2MI. A fair Kappa index, 0.386, and a McNemar difference of 0.0892 (P < 0.001) were found. Among the 207 adjudicated MIs using the hs-cTnI assay, 67 (32%) were ICD coded as MI. Of the 140 patients not ICD coded as MI, 27 (19%) were T1MI and 113 (81%) were T2MI. For the ICD-coded MIs, 85% were T1MI and 15% T2MI. A moderate Kappa index, 0.439, and a McNemar difference of 0.0674 (P < 0.001) were found. CONCLUSIONS: ICD-9-coded MIs captured only a small proportion of adjudicated MIs, primarily from not coding T2MI. Our findings emphasize the need for an ICD code for T2MI.
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Clasificación Internacional de Enfermedades/estadística & datos numéricos , Infarto del Miocardio/diagnóstico , Humanos , Troponina I/análisisRESUMEN
Complications related to central venous line use are known to increase patient morbidity and mortality and increase costs and length of hospital stay. Education programs to promote best central line practice have been shown to reduce central line complications. The purpose of this research was to demonstrate the effectiveness of an education module on staff compliance regarding central line care policy in the pediatric cardiovascular intensive care unit (CVICU). A quasi-experimental pre and post-test design was conducted in the CVICU at a major pediatrics hospital in the Southwest. A self-study module was distributed to all RN's working in the CVICU. Pre and post-test results were used to analyze the effectiveness of the education module. Compliance with central line care policy was scored as a "yes" or "no" based upon 10 observable policy requirements. Data was collected on 47 patients over a 1 to 2-month period pre and post intervention during rounds in the CVICU. Results show a marked improvement in compliance with policy.
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Actitud del Personal de Salud , Cateterismo Venoso Central/enfermería , Cuidados Críticos/normas , Educación Continua en Enfermería/organización & administración , Capacitación en Servicio/organización & administración , Personal de Enfermería en Hospital , Benchmarking , Competencia Clínica/normas , Evaluación Educacional , Medicina Basada en la Evidencia , Adhesión a Directriz/normas , Conocimientos, Actitudes y Práctica en Salud , Humanos , Unidades de Cuidado Intensivo Pediátrico/organización & administración , Investigación en Educación de Enfermería , Personal de Enfermería en Hospital/educación , Personal de Enfermería en Hospital/psicología , Política Organizacional , Enfermería Pediátrica/educación , Enfermería Pediátrica/normas , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Sudoeste de Estados UnidosRESUMEN
The article reports the case of a 39-year-old male who was diagnosed with and treated for bipolar disorder. Over the past 18 months, the patient has experienced new onset of auditory hallucinations and worsening of his psychotic symptoms. The treating psychiatrists changed the diagnosis from bipolar disorder to schizoaffective disorder. The authors discuss hierarchical and nonhierarchical approaches to psychiatric diagnosis in relation to this case report.